Download Hepatitis A - National Health Care for the Homeless Council

Hepatitis A
Lori Fantry, MD, MPH
H
epatitis A, once called “short incubation” or “infectious” hepatitis, is a
viral infection that involves the liver. Infection with hepatitis A leads to
symptoms that are very similar to other types of hepatitis. Unlike hepatitis
B and C, hepatitis A is rarely fatal and does not lead to chronic liver disease.
Nonetheless, hepatitis A is a significant cause of illness and suffering in many parts
of the world, including the USA.
Prevalence and Distribution
Hepatitis A is common throughout the world.
In the developing countries, the incidence of
hepatitis A is very high due to overcrowding and
poor sanitation. The highest rates in the USA are in
Arizona, Alaska, Oregon, New Mexico, and Utah.
Approximately 33% of persons living in the USA
have been infected with hepatitis A.
Mode of Transmission
Hepatitis A virus is spread primarily by the
fecal-oral route, either through person-to-person
contact or ingestion of contaminated food or water.
Transmission is often facilitated by poor personal
hygiene, lack of sanitation, and oral-anal sexual
contact. Common sources of contaminated food
include shellfish, frozen raspberries and strawberries, and milk.
Hepatitis A virus can also be directly transmitted through transfusions of blood or blood
products, although this is much less common due
to the brief period of time that hepatitis A virus
remains in the blood of an infected person. The
increased risk for hepatitis A infection among drug
users is primarily due to poor hygiene rather than
transmission through blood.
Children born to mothers with past or present
hepatitis A infection are not at risk for infection in
utero or at birth unless the mother is jaundiced at
the time of delivery. Breastfeeding is not a mode
of transmission. Urine and saliva do not transmit
hepatitis A virus.
About half the time, the person transmitting
hepatitis A virus cannot be identified. Often
the source identified is a young child with no or
minimal symptoms. Stools of infected persons are
infectious from approximately 2 weeks before until
about 1 week after the appearance of yellow skin
(jaundice). The most infectious period is before
jaundice appears.
Symptoms and Diagnosis
The clinical course of hepatitis A varies from
person to person. Some people, especially infants
The Health Care of Homeless Persons - Part I - Hepatitis A
29
BHCHP nurse
practitioner Jennifer
Burroughs and
family advocate
Jocelyn Beverly
perform a well-child
examination at the
Milner Hotel.
Photo by
David Comb
less than two years old, never develop symptoms
after infection. Older people have a higher
frequency of symptoms and tend to get a more
severe illness. Symptoms usually develop within 28
days after exposure. This period of incubation may
be as short as 15 days or as long as 50 days. Initial
symptoms usually include fever, fatigue, poor appetite, nausea, and vomiting. Diarrhea occurs more
commonly in children (see Table 1). Cough, sore
throat, coryza (runny nose and eyes), and arthralgias
(joint aches) have been reported in some outbreaks.
As with other types of hepatitis, hepatitis A can alter
taste and smell.
After several days to a week, the initial symptoms usually begin to diminish (see Figure 1). At
this point, the infected person may develop yellow
skin and eyes, dark urine, light stools, itching,
and abdominal pain. Weight loss may continue
throughout the illness. In most cases, symptoms of
hepatitis A resolve within 1 to 2 months.
Once infected with hepatitis A virus, a person is
immune from further infection with hepatitis A for
life. There is still a risk, however, from other types
of hepatitis.
Hepatitis A cannot be differentiated from other
types of hepatitis by symptoms alone. A blood
test, the immunoglobulin M antibody to hepatitis
A (IgM anti-HAV), is obtained to diagnose acute
hepatitis A. This test becomes positive 5-10 days
before the onset of symptoms and remains positive
for up to 6 months after infection. IgG anti-HAV
also becomes positive early in the course of infection, but usually remains positive for life and thus
cannot be used to differentiate present from past
infection. However, IgG anti-HAV is useful in
determining whether or not a person is a candidate
for hepatitis A vaccination.
Symptoms of
Hepatitis A in
Children and Adults.
Modified from
Lemon, SM. Type A
viral hepatitis.
New developments
in an old disease.
New England Journal
of Medicine, 1985.
Treatment and Complications
No specific treatment is available for hepatitis A.
Certain measures can alleviate the symptoms. Bed
rest may provide some comfort. If the person is
having frequent vomiting, caregivers should watch
for signs of dehydration.
Infected people should avoid alcohol and drugs,
legal and illegal, that are metabolized or broken
down by the liver. For this reason, aspirin is a safe
alternative to acetaminophen (Tylenol™) for fever
and muscle aches except in children less than 18
years old who are at risk for a liver-brain disorder
called Reye syndrome.
Although most people with hepatitis A recover
completely within 1 to 2 months, 10-15% have
a prolonged or relapsing disease. In addition,
about 100 persons per year in the United States
die from acute liver failure due to hepatitis A.
This most commonly occurs in persons over 50
years old and those with chronic liver disease.
Prevention and Control
Basic Precautionary Measures
All states require that each case of hepatitis A
be reported to the local or state health department.
The early symptoms of hepatitis A are similar to
many other diseases and are hard to recognize until
jaundice appears. As noted above, jaundice may
never arise in some cases.
Thorough hand washing is an essential part of
preventing the spread of any infection, including
hepatitis A. Hand washing is especially important
before preparing or serving food and after diapering
and using the bathroom. Caregivers should always
wear gloves when handling stools and should wash
hands after removing the gloves.
Persons with hepatitis A do not require any
Table 1: Symptoms of Hepatitis A in Children and Adults
Symptom
Children 2-5 years old
(day-care center outbreak)
Adults 18-26 years old
(U.S. Army soldiers)
Nausea/vomiting
11(65%)
5(26%)
Jaundice/yellow eyes
11(65%)
16(88%)
Diarrhea
10(58%)
3(18%)
Dark urine
10(58%)
12(68%)
Light-colored stools
10(58%)
10(58%)
Abdominal pain
8(48%)
7(37%)
Malaise/fatigue
8(48%)
11(63%)
Fever/chills
7(41%)
6(32%)
Decreased appetite
7(41%)
8(42%)
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The Health Care of Homeless Persons - Part I - Hepatitis A
Figure 1:
The Clinical Signs
and Serology of
Hepatitis A Infection.
Viral shedding of
hepatitis A virus is
present in the stool
about two weeks
after initial exposure.
The timing of clinical
symptoms
and various
serological markers
are shown here.
Courtesy of the CDC
special type of isolation unless they are incontinent
of stool. Infected people who regularly handle food
should avoid tasks that require direct contact with
food until 1 week after the appearance of jaundice.
Post-Exposure Immunization
An immunization containing antibodies, called
immunoglobulin or IG, against the hepatitis A
virus can limit the spread of the virus. When given
within 2 weeks of exposure, the immunization will
lessen the severity of illness and totally prevent
clinical signs and symptoms in some cases.
Those who should receive IG include:
• household contacts of the infected person
(see Special Considerations for Homeless
Populations);
• sexual contacts of the infected person;
• persons who have shared illegal drugs with
the infected person;
• staff or day care centers with at least one
infected child;
• other food handlers at the same establishment of a food handler known to be
infected.
Prevalence of
Hepatitis A. These
states have > 20
cases of hepatitis
A per 100,000
population. Modified
from Prevention of
hepatitis A through
active or passive
immunization.
Recommendations
of the Advisory
Committee on
Immunization
Practices (ACIP).
MMWR 1999;48
(RR-12):1-37.
Table 2: States with ≥ 20 Cases per 100,000 Population of Hepatitis A
State
Arizona
Alaska
Oregon
New Mexico
Utah
Washington
Oklahoma
South Dakota
Idaho
Nevada
California
Rate (per 100,000)
48
45
40
40
33
30
24
24
21
21
20
The Health Care of Homeless Persons - Part I - Hepatitis A
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The recommended dose of IG for postexposure
prophylaxis is 0.02 mL/kg. Side effects from IG
other than pain and tenderness at the injection site
are extremely rare. IG has never been reported to
transmit other viruses, including human immunodeficiency virus (HIV), hepatitis B, or hepatitis C.
Pre-Exposure Immunization
Persons who are at increased risk for developing
infection or have increased risk of severe disease
should receive hepatitis A vaccination. These
include:
• sexually active men who have sex with
men;
• drug users (injection and non-injection);
• persons with chronic liver disease;
• children living in states, counties, or communities where the average annual hepatitis A rate during 1987-1997 was greater
than or equal to 20 cases per 100,000
population (see Table 2);
• persons who have clotting factor disorders;
• persons traveling to or working in countries with high or intermediate rates of
hepatitis A;
• persons who work with HAV-infected
primates or with HAV in a research laboratory setting.
The two vaccines approved for active immunization against hepatitis A virus (HAVRIX™
and VAQT™) are both inactivated vaccines. Both
vaccines are given in two doses at least 6 months
apart. The doses differ depending on the age of
the patient and which product is used. Present
data suggest that immunity may be lifelong and
repeat vaccination after the initial series is not
recommended. About 50% of persons receiving the
hepatitis A vaccine experience soreness at the injection site, but other side effects are extremely rare.
Special Considerations for Homeless Populations
Homeless people are often at high risk for hepatitis A due to overcrowded and unsanitary living
conditions. In addition, homeless persons may use
illegal drugs or have chronic liver disease. Homeless
persons with these risk factors should receive active
immunization against hepatitis A.
Hepatitis A can spread rapidly through a shelter
if certain precautions are not followed. The local or
state public health department should be informed
of any cases of hepatitis A as soon as possible. They
can evaluate the situation and determine who should
32
be immunized with IG. Whenever a child still in
diapers develops hepatitis A in a family shelter, all
children, parents, and staff should receive IG.
Summary
Hepatitis A is a viral infection of the liver that
may cause a short-term sickness but generally does
not cause prolonged liver disease. Both children
and adults are affected. Adults tend to have a more
severe course of illness. In fact, many children
are infected but never show signs of hepatitis. A
person can only become infected once in his or her
lifetime. An infected person may develop cold- or
flu-like symptoms from 15-50 days after exposure
to the virus. The typical signs of hepatitis appear a
few days later: yellowing of the skin and eyes, dark
urine, itching, and abdominal pain. The illness
usually lasts 4 to 8 weeks.
Hepatitis A usually spreads by direct contact
with an infected person and less commonly through
fecal contamination of food or water. Those at
highest risk include travelers or persons from
developing countries, children (and secondarily staff
and parents) in day-care centers, men who have sex
with men, injection drug users, hemophiliacs who
have received pooled blood products, and persons
in institutions.
Persons at risk for hepatitis A can receive active
immunization with a formalin-inactivated vaccine
to prevent infection. In addition, persons who have
recently been exposed to hepatitis A and have not
been vaccinated can receive IG. This will provide
passive immunization that can lessen or completely
abort the symptoms and manifestations of the
disease.
No specific treatment exists for hepatitis A, but
certain measures can ameliorate the symptoms. Bed
rest, high calorie foods, and aspirin can help with
the symptoms of muscle aches, abdominal pain, and
fevers. Remember that aspirin should be avoided
in children under the age of 18 because of the risk
of Reye syndrome. Prescription medications can
relieve itching. E
The Health Care of Homeless Persons - Part I - Hepatitis A
References
Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization.
Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48(RR-12):
1-37.
Dienstag JL, Isselbacher KJ. Acute viral hepatitis. In: Braunwald E, Fauci AS, Kasper DL, et al., eds. Harrison’s
Principles of Internal Medicine. New York: McGraw-Hill; 2001:1721-1737.
Hoofnagle JH, Lindsay KL. Acute viral hepatitis. In: Goldman L, Bennett JC, eds. Cecil Textbook of Medicine.
Philadelphia: WB Saunders Company; 2000:783-790.
Lemon S. Type A viral hepatitis. New developments in an old disease. New England Journal of Medicine 1985;313(17):
1059-1067.
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Several street folks seek refuge each night in
this South Boston junkyard for abandoned or
demolished trucks and buses. The city’s skyline
is in the background.
Photo by James O’Connell MD